Key Facts

Smoking remains the single largest preventable cause of morbidity and mortality in the UK. Despite declining prevalence, it continues to cause enormous health and economic burden, with stark socioeconomic inequalities. Effective cessation treatments exist and are highly cost-effective.

Epidemiology

• Smoking prevalence in England: ~12-13% (2022); down from ~46% in 1974
• Socioeconomic gradient: prevalence ~25% in most deprived quintile vs ~6% in least deprived
• ~76,000 deaths/year in England; ~500,000 hospital admissions attributable to smoking
• Smoking in pregnancy: ~9% at time of delivery; leading modifiable risk factor for adverse pregnancy outcomes
• Smokeless tobacco: betel/paan use in South Asian communities — oral cancer risk
• E-cigarette use: ~3.6 million adults in England use vapes; primarily current or ex-smokers

Aetiology

• Nicotine: primary addictive component; binds nicotinic acetylcholine receptors (nAChRs), particularly α4β2 subtype in the ventral tegmental area
• Neurobiological: nicotine → dopamine release in nucleus accumbens → reinforcement; tolerance develops rapidly
• Behavioural: conditioning to environmental cues (after meals, with alcohol, stress); habitual behaviour deeply ingrained
• Psychosocial: peer influence (particularly in adolescent initiation), stress coping, social identity
• Industry: tobacco product design optimises nicotine delivery and addiction

Pathophysiology — Smoking-Related Disease

• Cardiovascular: accelerated atherosclerosis, endothelial dysfunction, prothrombotic state
• Respiratory: chronic inflammation, mucus hypersecretion, protease-antiprotease imbalance → COPD; direct carcinogenesis → lung cancer
• Carcinogenesis: >70 known carcinogens in tobacco smoke (nitrosamines, polycyclic aromatic hydrocarbons, benzene)
• Other organ damage: renal impairment, peptic ulcer disease, osteoporosis, age-related macular degeneration

Nicotine Dependence Assessment

• Fagerström Test for Nicotine Dependence (FTND): 6-item questionnaire
  • Most predictive item: time to first cigarette after waking (<5 minutes = high dependence)
  • Score: 0-3 low, 4-6 moderate, 7-10 high dependence
• Heaviness of Smoking Index (HSI): 2-item abbreviated version (cigarettes per day + time to first cigarette)
• Carbon monoxide (CO) reading: expired CO >10 ppm consistent with active smoking

Smoking-Related Diseases

• Cardiovascular: coronary artery disease, peripheral arterial disease, stroke, aortic aneurysm
• Respiratory: COPD (accounts for ~80% of COPD cases), lung cancer, asthma exacerbation
• Cancer: lung (~72% attributable to smoking), oral cavity, oesophageal, bladder, kidney, pancreatic, cervical
• Other: type 2 diabetes (50% increased risk), peptic ulcer disease, osteoporosis, cataracts, impaired wound healing, erectile dysfunction

Nicotine Withdrawal

• Onset: within 2-12 hours of last cigarette
• Peak: 24-72 hours
• Duration: physical symptoms improve over 2-4 weeks; cravings may persist for months
• Features: irritability, anxiety, restlessness, difficulty concentrating, increased appetite, depressed mood, insomnia

Red Flags

• Haemoptysis in a smoker: urgent 2-week-wait cancer referral
• Weight loss and new persistent cough: suspect lung malignancy
• New claudication symptoms: peripheral arterial disease
• Smoking in pregnancy: counsel on risks (low birth weight, preterm birth, stillbirth, SIDS); offer NRT

Bedside

• Expired carbon monoxide (CO): >10 ppm = active smoker; used to verify quit status; <4 ppm = non-smoker
• Fagerström Test/HSI: assess dependence severity
• Comprehensive smoking history: pack-years (packs/day × years smoked)
• Very Brief Advice: ASK, ADVISE, ACT at every healthcare contact

Bloods

• Cotinine level (urine or blood): metabolite of nicotine; gold standard for verifying smoking status; used in research and insurance
• FBC: polycythaemia in heavy smokers
• Lipid profile: dyslipidaemia
• HbA1c/glucose: diabetes risk assessment

Imaging

• Chest X-ray: if respiratory symptoms or suspected malignancy
• Low-dose CT thorax: NHS Lung Health Check programme — targeted lung cancer screening for 55-74 year olds with ≥20 pack-year history
• Spirometry: if COPD suspected

Special Tests

• ECG: baseline cardiovascular assessment if significant risk factors
• Abdominal aortic aneurysm screening: men aged 65 — smoking is the major modifiable risk factor

Non-pharmacological

• Very Brief Advice (VBA): recommended at every healthcare contact (NICE PH1, NICE NG209)
  • ASK: establish smoking status
  • ADVISE: "the best thing you can do for your health is to stop smoking"
  • ACT: refer to stop smoking service, prescribe pharmacotherapy, or offer self-help
• Behavioural support: stop smoking services provide structured support; doubles quit rates compared to pharmacotherapy alone
• Group or individual counselling: both effective; patient preference
• NHS Stop Smoking Services: free; combination of behavioural support + pharmacotherapy; 4-week quit rates ~50%; CO-verified abstinence at 12 months ~15-20%

Pharmacological

• Varenicline (Champix) 0.5 mg OD for 3 days, then 0.5 mg BD for 4 days, then 1 mg BD for 12 weeks (can extend to 24 weeks):
  • Partial agonist at α4β2 nAChR: reduces craving and withdrawal; blocks reward from smoking
  • Most effective single therapy: OR ~2.2-2.9 vs placebo for 6-month abstinence
  • EAGLES trial (2016): no increased neuropsychiatric risk compared to NRT or placebo
  • Side effects: nausea (most common), vivid dreams, headache
  • Note: supply issues from 2021; alternatives needed when unavailable
• Nicotine Replacement Therapy (NRT):
  • Increases quit rates by 50-60%; available OTC and on prescription
  • Combination therapy most effective: long-acting (patch) + short-acting (gum, lozenge, inhalator, nasal spray, mouth spray)
  • Patch: 21 mg/24h (heavy smokers), 14 mg/24h, 7 mg/24h — step-down over 8-12 weeks
  • Gum: 2 mg or 4 mg (for highly dependent smokers)
  • Inhalator, nasal spray, lozenge, mouth spray: for breakthrough cravings
  • Safe in cardiovascular disease; safe in pregnancy (preferable to smoking)
• Bupropion (Zyban) 150 mg OD for 6 days, then 150 mg BD for 7-9 weeks:
  • Noradrenaline and dopamine reuptake inhibitor
  • OR ~1.6 vs placebo
  • Contraindicated: seizure disorders, eating disorders, bipolar, concurrent MAOIs
• Cytisine (Desmoxan): partial nAChR agonist; emerging evidence of efficacy similar to varenicline; natural plant alkaloid; increasingly available
• E-cigarettes/vapes: not licensed medicines but endorsed by OHID (Office for Health Improvement and Disparities) as cessation aid; ~twice as effective as NRT (Hajek et al., NEJM 2019); swap-to-stop schemes in NHS

Surgical

• Not applicable to smoking cessation specifically

Referral Criteria

• NHS Stop Smoking Service: all smokers motivated to quit; GPs can refer directly
• Specialist services: pregnant smokers (specialist midwifery), mental health inpatients (higher smoking rates), secondary care inpatients (hospital smoking cessation teams)
• Respiratory/oncology: for smoking-related disease management alongside cessation support

Benefits of Cessation

• 20 minutes: heart rate and blood pressure begin to normalise
• 48 hours: CO eliminated; taste and smell improving
• 1 year: CVD risk halved compared to continuing smoker
• 10 years: lung cancer risk halved compared to continuing smoker
• 15 years: CVD risk equivalent to never-smoker
• Stopping at age 30: gain ~10 years life expectancy; stopping at age 60: gain ~3 years

Complications of Continued Smoking

• Life expectancy reduction: smokers die on average 10 years earlier than non-smokers
• COPD: progressive, irreversible airflow limitation; leading cause of respiratory disability
• Lung cancer: ~47,000 cases/year in UK; 5-year survival ~15-20% overall
• Cardiovascular disease: 2-4× risk of CAD; 2× risk of stroke
• Economic cost: estimated £2.4 billion/year to the NHS

Quit Attempt Statistics

• ~60% of smokers want to quit; ~30% make a quit attempt each year
• Unaided quit attempts: ~3-5% success at 12 months
• Pharmacotherapy alone: ~10-15% at 12 months
• Pharmacotherapy + behavioural support: ~15-25% at 12 months
• Average smoker makes ~7 quit attempts before successfully stopping long-term

Smoking Cessation Pharmacotherapy Comparison

Fagerström Test Items

Key Landmark Studies